New Fact Sheet Explains Medicare Coverage for People with End Stage Renal Disease

New Fact Sheet Explains Medicare Coverage for People with End Stage Renal Disease

Written for people with Medicare solely because of end stage renal disease (ESRD), this new fact sheet clearly defines how one qualifies for Medicare, when coverage begins and ends, how it coordinates with employer or union group health plans, and options for other supplemental coverage. Details that are often glossed over or misleading in other publications, such as explanations on options and consequences for delaying Medicare enrollment when qualifying for ESRD Medicare, are clearly explained.
Some such details covered in the fact sheet include:

  • People who are younger than 65 with ESRD, do not have the option of purchasing Medicare Part A if they don’t qualify for premium free Part A. They only have this option if they are 65 years old or older, and are a U.S. citizen or legal immigrant with a green card who has lived in the U.S. for at least 5 consecutive years.
  • People with employer or union group health coverage can choose to delay enrolling in Part A and/or Part B during a 30-month coordination of benefits period, BUT delaying enrollment in both parts or just Part B of Medicare determines whether one will be charged a premium penalty when later enrolling in Part B.
    • People who only enroll in Medicare Part A and defer enrolling in Part B to avoid paying the Part B monthly premium during the 30- month coordination period, will be charged a premium penalty when they later enroll in Part B. They also can only enroll during the General Enrollment Period (GEP), which is between January 1 and March 31 of each year with Part B benefits beginning in July of that year.
    • Yet, people who delay enrolling in BOTH Parts A and B during the 30-month coordination period, can sign up for both parts of Medicare anytime during those 30 months. They are not restricted to only signing up during the GEP. They will not be charged a premium penalty as long as they continue to be eligible for employer group coverage through their employment or a qualified family member’s employment.
  • People can enroll in ESRD Medicare Parts A and B retroactively up to 12 months. Therefore, if someone does not have Part A when they have their transplant, as long as they can sign up for Part A within 12 months of their transplant, they can then get their Medicare retroactive to their transplant date. This is important for securing eligibility for the immunosuppressive drug coverage under Part B. A person must have Part A coverage at the time of their transplant to be eligible for this Part B drug benefit, and getting coverage retroactive meets this requirement.
  • If a person with ESRD is in a Medicare Advantage Plan that leaves the Medicare program, or no longer provides coverage in their area, they have a one-time right, a special enrollment period (SEP), to join another Medicare Advantage plan regardless of whether another plan is currently available where you live. This one-time enrollment right has no timeframe. It is indefinite and continues until they select a new MA plan.

Also, if a person moves to another service area or state and has not used their one-time SEP, they still have their SEP and can use that one-time enrollment right to enroll in an MA plan in their new location.

This fact sheet is both an excellent reference for advocates and counseling tool when working with Medicare beneficiaries with ESRD.

View or download this fact sheet, “Medicare and People with End Stage Renal Disease,” online.

Our blogger Karen J. Fletcher is CHA's publications consultant. She provides technical expertise, writing and research on Medicare, health disparities and other health care issues. With a Masters in Public Health from UC Berkeley, she serves in health advocacy as a trainer and consultant. See her current articles.